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Based on interview and record review, the hospital failed to maintain the list of on-call physicians with accurate names and contact information from December 2014 to May 2015.

Findings:

Record review showed the following services which did not list specifically the on-call physicians for the listed services or did not have the phone number to contact the physician on-call for the months of December 2014 to May 2015: medicine, cardiology, GI, neurology, general surgery, ENT, plastic maxilla facial and oral surgery, cardiac, urology, ophthalmology, obstetrics and gynecology, pediatrics, orthopedic, podiatry, and surgical assistants.

During an interview on 5/18/15 at 3:00 PM, MD-3 stated the on-call physicians would be called to consult on the phone and would not come to the Coastside ED. He stated there are several ways to obtain the contact information for an on-call physician such as on the hospital computer or by calling the hospital operator. He stated he would call Facility-A or Facility-B if he needed consult on psychiatric patients. He also stated the ED Coastside would not use the surgical assistant on-call list at all.

During the same interview, Administrator-1 and QAPI Director stated the on-call list is used for the entire hospital and not just for the Coastside ED.

Based on interview and record review, the facility failed to maintain their central log for completeness when patient ESI Levels were not indicated for the months of September 2014 to May 2015.

Findings:

Record review revealed the following months that had incomplete information in the ED log for patients who were admitted to the ED:
1) September 2014: there were 27 patients who did not have ESI Levels
2) October 2014: there were 12 patients who did not have ESI Levels
3) November 2014: there were 4 patients who did not have ESI Levels
4) December 2014: there was 1 patient who did not have an ESI Level
5) January 2015: there was 1 patient who did not have an ESI Level
6) February 2015: there was 1 patient who did not have an ESI Level
7) March 2015: there were 4 patients, who did not have an ESI Level
8) April 2015: there were 2 patients, who did not have an ESI Level
9)May 1 - May 13 2015: there was 1 patient who did not have an ESI Level

The facility ' s policy and procedure titled, " Emergency Treatment & Active Labor Act (EMTALA), Compliance With " , date revised 5/14, showed the following regarding the central log: " Each department of the Medical Center that provides medical screening examinations shall maintain a central log recording the names of patients who present for emergency services. The log shall record the name of each person who presents for emergency services and whether the person refused treatment, was refused treatment by the Medical Center or whether the patient was transferred, admitted and treated, stabilized and transferred, or discharged. Each department shall establish its own central log policy and procedure for additional information in the log, timely recording of log entries and maintaining completed logs.

During an interview on 5/18/15 at 3:00 PM, RN-1, MD-3, Administrator-1, and the QAPI Director did not know who was responsible for maintaining the ED log.

Based on interview and record review, the facility failed to appropriately transfer 14 of 31 sampled patients to other health facilities (Patients 1, 4, 5, 15, 19, 20, 24, 25, 26, 27, 29, 30, 31, and 32). These patients were transferred by friends or family in privately owned vehicles rather than with qualified personnel and transportation equipment. This deficient practice did not ensure the safe transport and monitoring of patients still requiring further medical treatment from receiving hospitals. Additionally, the facility failed to follow a consistent process in obtaining patient consent for transfer. Some providers would use the transfer forms established by the hospital in various manners while others would use an AMA form or both, or none at all. The providers would use an AMA form when a patient refused ambulance transport to transfer to the receiving hospital.

Findings:

1. Patient-1 was admitted to the ED on 10/26/14 at 8:40 PM with a chief complaint of Tylenol overdose. The patient was 14 years old and was brought in by her mother after she ingested eight extra strength Tylenol pills trying to commit suicide. The patient was triaged at 9:20 PM and was given an ESI Level 3. The medical record showed the physical exam done by the physician was charted at 12:19 AM. The ED physician consulted with Poison Control and documented the following: " Pt. asymptomatic at present. Discussed with poison control who advised 8 500 mg pills potentially toxic and will need a 4 hour level at midnight. No advantage to drawing it now but will need other lab to r/o other abnormalities (tox screen, alcohol, ASA, baseline LFT, etc.) As no lab here other than send outs with some delay in resulting and since needs psych evaluation in any case I advised mother prudent to transfer now to higher level of care where they can get more rapid results, admit for n-acetylcysteine and get psych evaluation ...Patient is cooperative and agrees with transfer. Mother wants to take pt. in car. Will send directly to (Facility-A ' s ED) with mother " . Records showed Facility-A accepted Patient-1 for transfer. The transfer consent form was signed by the patient ' s mother. The consent form showed under the section titled, " Transfer Requirements " , the following choices to choose from: " C. The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures. (The choices are) BLS Ambulance, ALS Ambulance, Air Transport, Other. (There is a section to list personnel such as physician, registered nurse, respiratory therapist and also a section to list equipment). The facility checked " Other " , and " Private Car Driven by Mother - Pt. Cooperative " was handwritten to indicate what " Other " meant. The disposition status was stable and was logged as a transfer. The transfer document showed the transfer occurred at 10:00 PM. The final diagnosis was Tylenol overdose and suicidal ideation. Record review did not reveal any other consent signed by the patient ' s parent other than the consent form for transfer.

During a phone interview on 5/08/15 at 4:15 PM, Patient-1 ' s mother stated although she signed the consent documents for transfer, she was certain that the physician did not discuss with her the risks and benefits of transferring her own daughter in her car nor was an ambulance discussed as an option for transfer.

During an interview on 5/08/14 at 1:05 PM, RN-1 was asked how patients who are brought in a privately owned vehicle were ensured that a proper transfer occurred wherein the patient successfully made it to the recommended facility safely. RN-1 stated, " The other hospital would call us if the patient never made there " . The same nurse was also asked if the facility had a policy and procedure addressing patients who are transferred in privately owned vehicles and she stated, " The previous ED director was working on a policy for private car transfers but she never finished " .

During another interview on 5/13/15 at 3:30 PM, MD-1 stated, " There is no mechanism to ensure patients arrive safely to another facility when transferred in a private car ..., I can think of two instances where EMTALA regulations allow for private auto transfers: 1. Reliability and 2. Refusal of ambulance " .

On another interview on 5/18/15 at 2:50 PM, Director of QAPI confirmed there was no policy and procedure regarding emergency room patients who are transferred in privately owned vehicles.

The facility ' s policy and procedure titled, " Transfer of Individuals with Emergency Medical Conditions " , date revised 9/14, showed the following: " Appendix A EMTALA definitions ...EMERGENCY MEDICAL CONDITION - a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: A. Placing the health of an individual (or, with respect to a pregnant woman, the health of her unborn child) in serious jeopardy, B. Serious impairment of bodily functions, C. Serious dysfunction of any bodily organ or part ..., TRANSFER - the movement (including discharge) of an individual outside a hospital ' s facility at the direction of any person employed by (or affiliated or associated, directly or indirectly with) the hospital, but does not include such movement of an individual who has been declared dead or leaves the facility without permission of any such person ..., STABILIZED/MEDICAL - with respect to an emergency medical condition that no material deterioration of the condition is likely, with reasonable medical probability, to result from/or occur during, the transfer of the patient from the facility ..., A. Stable transfer. A patient is considered " stable " for transfer if the transferring physician has determined with reasonable clinical confidence that the patient may be transferred without material deterioration in his/her condition and the receiving facility has the capability to manage the patient ' s condition and any foreseeable complications of that condition ...STABILIZED/PSYCHIATRIC - Stable for Transfer. A psychiatric patient is considered " stable " for transfer if the treating physician has assessed the patient and determined to have no underlying organic basis for the presenting psychiatric symptoms; initial treatment has been provided as indicated; and the patient has been treated sufficiently so that he/she is no longer a threat to themselves or others ... " .

This same policy and procedure described transfers of patients who do and do not have an emergency medical condition. For patients who do not have an emergency medical condition, the policy stated: " A. When an individual is determined as a result of a medical screening examination not to have an emergency medical condition, the individual may be transferred to another health care facility (if in need of further care) or discharged (if not in need of further care). 1) Transfer of patients to another facility would be undertaken as a result of lack of capacity or capability to provide the care at Seton Medical Center, at the patient ' s or family ' s request or at the request of the Attending Physician. The transfer would be executed according to standing policies for Acute-to-Acute Transfer Out currently in place at Seton Medical Center ... " , 2) Discharge of patients not needing further care would be undertaken if the patient meets standard discharge screens and if the discharge can be completed in a safe manner " .

For patients who do have an emergency medical condition, the policy stated: " A. When it is determined that the individual has an emergency medical condition, the Medical Center shall: 1) Within the capability and capacity of the staff and facilities available at the Medical Center stabilize the individual; or 2) provide, if applicable, for the appropriate transfer of the individual to another medical facility in accordance with established procedures " . Furthermore, the policy discussed " Transfer of an Unstable Individual With an Emergency Medical Condition " with the following: " ...The transfer shall be executed by qualified personnel and adequate transportation equipment, as determined by the physician, including the use of necessary and medically appropriate life support measures during the transfer ..., Procedure for Transfer by Ambulance: 1) When the receiving hospital provides its own ambulance service, the receiving physician should arrange for ambulance transfer. 2) For those patients requiring routine transport advanced life support skills, an EMT BLS unit shall be called. 3) For those patients requiring advanced life support monitoring skills: a) A Critical Care Transport Unit may be arranged as needed by calling the appropriate ALS provider ... " .

The facility ' s policy and procedure titled, " Acute-to-Acute Patient Transfer " , revision date 7/08, showed the following: " Out-Bound Acute-to-Acute Transfers: 1. Seton Medical Center will transfer patients out of the facility based on clinical need and unavailability of services or patient, family or physician preference. 2. Patients being considered for transfer fall into one of two classifications: a. Emergent, b. Non-Emergent ..., 4. Emergent patients may only be considered for transfer if: a. Service required are unavailable at Seton Medical Center, b. The receiving facility is the closer acute hospital geographically to Seton Medical Center that is willing to accept the patient and has the clinical capability to meet the care needs of the patient, c. Risks of transfer have been judged against the benefit of the transfer by a qualified medical physician and it has determined and documented that the benefit outweighs the risk, d. Risks and benefits of the transfer have been explained to the patient and documented, e. All appropriate transfer paperwork has been completed by Seton Medical Center prior to transfer ..., f. The receiving hospital has agreed to accept the patient, g. An appropriately licensed medical physician on staff at the receiving facility has agreed to accept the patient of the Emergency Department has agreed to the transfer. 5. Non-emergent patients may only be considered for transfer if: a. Services required are unavailable at Seton Medical center or the transfer is being initiated based on patient, family or physician preference. b. Risks of transfer have been judged against the benefit of the transfer by a qualified medical physician and it has been determined and documented that the benefit outweighs the risk ... " . Neither of the policies discussed patients who are transferred by privately owned vehicles.

2. Patient-4 was admitted to the ED on 12/22/14 at 7:14 AM with a chief complaint of migraine dizziness. The patient was triaged at 7:25 AM and was given an ESI Level 3. The physical exam by the physician was charted at 8:01 AM. The patient had an incision and drainage of an abscess behind the right ear on 12/19/14. The ED RN documented the patient had pain, nausea, dizziness, headache and photophobia. Patient-4 was treated with Dilaudid for pain with effective results. The ED physician documented the following: " Pt. requires CT mastoid/head, unavailable at this site. Discussed at 08:00 (with Facility-B) who agrees to accept pt. in transfer for further eval. Pt. consents to transfer but refuses ambulance transport, preferring his girlfriend drive him, so he will sign AMA for ambulance transport " . The disposition status was stable and was logged as a transfer. As with Patient-1, Patient-4 had the same transfer documents and the mode of transfer was " Other " and " Private Vehicle " was handwritten to indicate what " Other " meant. The transfer document showed the transfer occurred at 8:30 AM. The final diagnosis was acute cephalgia and R/O right mastoiditis. Record review revealed Patient-4 signed both consent for transfer and an AMA for refusal of an ambulance for transport.

During an interview on 5/13/15 at 3:30 PM, MD-1 stated not all of the ED physicians will complete an AMA form for patients who refuse an ambulance for transfer. He stated, " I don ' t do an AMA for legal purposes " .

3. Patient-5 was admitted to the ED on 12/14/14 at 5:41 PM. The patient was a three month old infant brought in by the parent with a chief complaint of vomiting. The patient was triaged at 5:55 PM with an ESI Level of 3. The physical exam done by the physician was charted at 6:30 PM. The record showed transfer documents and consents for a transfer to Facility-C. The ED physician wrote: " Discussed with resident in ED at (Facility-C). Due to lack of capabilities here and to shunt malfunction being on the diagnosis for this patient, transfer to (Facility-C) for evaluation there is warranted " . As with the previous patients, the transfer document showed the patient was transferred by privately owned vehicle and that the transfer occurred at 6:35 PM. The disposition status was stable and was logged as a transfer. The final diagnosis was vomiting, irritability, R/O central nervous system shunt malfunction. Record review did not show whether ambulance transport was discussed with the parents and only consent for transfer was signed by Patient-3 ' s parent.

Further record review revealed a discrepancy of the transfer disposition from the ED nurse ' s documentation that showed the patient was discharged home: " At 7:22 PM: Patient discharged home, carried, family driving, accompanied by parent, Summary of care provided, The patient was provided an electronic copy of the discharge instructions, Transition record given to patient, Teaching, Simple or moderate discharge teaching performed (nurse and physician) ..., Discharge instructions given to mother ... " .

During an interview on 5/13/15 at 3:30 PM, MD-1 reviewed Patient-5 ' s medical document and could not give an explanation of the transfer and discharge discrepancies. At 4:00 PM on the same day, Administrator-1 stated the nurse who authored the ED document could not be interviewed because she was on leave.

4. Patient-15 was admitted to the ED on 4/11/15 10:55 PM with a chief complaint of left foot throbbing 7/10 pain and swelling for two days. The patient was triaged at 11:13 PM and had an ESI Level 2. The patient had a history of blood clots and a heart attack in January 2015. The physician ' s physical exam was charted at 12:11 AM and showed the following: " Patient appears uncomfortable ..., appears in pain ..., pulse is outside normal limits ..., has swelling and tenderness of the distal most lower leg and ankle, medial side more pronounced than lateral. Hyperemic there but not really erythematous such as to suggest infection and other leg is also hyperemic but not swollen or tender ... " . The physician further documented: " Pt. concerned about possible (blood clot) and given (history) of same, not on max (blood thinners) treatment, (history) of active (cancer) and on (chemotherapy) has major risk factors for this. Given all this advised he needs ultrasound and we do not have ultrasound at this hospital. Pt. prefers to go to (Facility-B). Called there and talked to charge RN who advises send the pt. (Facility-B ' s physician) will be accepting MD. Pt. refuses ambulance and risks explained and still refuses. Will drive directly there with transfer form and will (fax) this record now prior to pt. arrival there " . The disposition status was stable and was logged as a transfer. As with the previous patients, the transfer document showed the patient was transferred by privately owned vehicle and that the transfer occurred at 11:50 PM. The final diagnosis for Patient-15 was R/O blood clot in the left leg. Record review showed only a consent for transfer was signed by Patient-15 and no AMA form was signed for ambulance refusal.

5. Patient-19 was admitted to the ED on 3/14/15 at 8:12 PM for a chief complaint of Advil overdose. The patient was triaged at 8:30 PM and had an ESI Level 2. The record showed the patient was 15 years old and ingested fifteen 200 mg Advil tablets at 7:30 PM and admitted to wanting to kill herself. The physical exam done by the physician was charted at 8:47 PM and showed the following: " Patient appears in pain ..., blood pressure is outside normal limits ..., remote memory poor, suicidal ideations present, tearful ..., Poison Control contacted: reported estimate (amount) ingested non-toxic, no interventions needed. Pt. will require emergent psych. eval; mother requested (Facility-A) but (Facility-A) Psych ED refused to accept because no inpatient beds available. (Facility-C) called. (Facility-C ' s physician) agreed to accept pt. in transfer; he is aware that all lab studies pending. Mother refuses ambulance transport - as she appears reliable, and there is low index of suspicion of concomitant toxic ingestion, I believe this is indeed safe - so mother will drive her there " . As with the previous patients, the transfer document showed the patient was transferred by privately owned vehicle and that the transfer occurred at 9:35 PM. The final diagnosis was acute suicidal ideation, non-toxic drug overdose. Instead of signing an AMA form refusing for an ambulance transport, the transfer consent form showed the mother signed for both an acknowledgement for transfer and refusal for transfer. The acknowledgement for transfer stated: " I understand that I have a right to receive a medical screening examination and evaluation by a physician, or other appropriate personnel, without regard to my ability to pay, prior to transfer from this hospital and that I have a right to be informed of the reasons, risks and benefits of any transfer. I acknowledge that I have received medical screening, examination and evaluation by a physician, or other appropriate personnel and that I have been informed of the reasons for my transfer " . And on the same page of the acknowledgement, the patient ' s mother also signed for " Patient Refusal to Transfer " which stated: " I understand that my physician has recommended that I be transferred to another health care facility. Despite this recommendation, I am REFUSING to be transferred. The potential benefits of going to another health care facility and the possible risks to my health by staying at this hospital have been explained to me and include, but are not limited to: (the following statement was handwritten) refusing ambulance POV to (Facility-C) directly " . The disposition status was stable and was logged as a transfer. Record review showed the patient ' s parent signed the transfer form only and not an AMA for ambulance refusal.

6. Patient-20 was admitted to the ED on 3/23/15 at 7:18 PM with a chief complaint of head injury after falling in the facility ' s skilled nursing unit. The patient was triaged at 7:21 PM and had an ESI Level 3. The physician ' s physical exam was charted at 7:35 PM and showed the following: " Blood pressure hypertensive ..., head exam included findings of head atraumatic, contusion to occipital, swollen but nontender area mid (occipital), about 3 cm (diameter), no (fracture) felt, pupils - cataract surgery ..., " DW pt. and I reco CT of head because of warfarin and pt. agreeable but did not want to go by ambulance. DW (MD-1) and she accepts pt. for transfer. Pt. will go up with son to ER ... " . But the same physician also documented: " Patient Plan: The patient will be discharged. The patient will follow up with primary care physician " . The final diagnosis was closed head injury. The disposition was logged as a transfer. As with the previous patients, the transfer document showed the patient was transferred by privately owned vehicle and that the transfer occurred at 7:50 PM. Record review showed the patient signed only a consent for transfer and not an AMA for ambulance refusal.

The disposition status on the transfer form was checked as " The patient ' s condition has not stabilized " by MD-2. On an interview on 5/18/15 at 9:00 AM, MD-2 stated that he couldn ' t remember the case but " the check mark (he) made on the transfer form would take precedence over a click made on the computer " . This patient had a different process from the previous patients who also refused an ambulance for transfer. On the transfer form, the words " refused ambulance " were hand written on the transfer consent and discharge instruction forms.

7. Patient-24 was admitted to the ED on 4/30/15 with a chief complaint of right lower abdominal pain since 1:00 AM. An initial greet time was not documented but the initial vital signs were taken at 6:39 AM. The patient was triaged at 6:42 AM and had an ESI Level 3. The physician ' s physical exam was charted at 7:20 AM and showed the following: " ...Abdomen tender, mild intensity, right lower quadrant ..., Discussed patient with (MD at Facility-A). Will transfer for further evaluation. The urine is (negative) for (white blood cells) or (red blood cells). Differential includes appendicitis, ureteral stone, cholelithiasis is possible but unlikely. Pt. will drive self to (Facility-A). Advised to remain NPO " . The final diagnosis was abdominal pain. The disposition status was stable and was logged as a transfer. The transfer document showed the patient was transferred by privately owned vehicle and that the transfer occurred at 7:25 AM. Record review did not show whether an ambulance transport was discussed with the patient and only a consent for transfer was signed by the patient.

8. Patient-25 was admitted to the ED on 5/05/15 at 10:47 AM with a chief complaint of head injury from a fall after tripping and a brief loss of consciousness. The patient was triaged at 10:54 AM and had an ESI Level 3. The physical exam done by physician was charted at 7:51 PM and showed the following: " Traumatic findings noted on head ..., head tender to palpation ..., traumatic findings noted to face, right forehead abrasion, face tender to palpation, right forehead ..., Her wounds were cleaned by myself and the ER nurse. Her examination did not show focal neurological (abnormalities). She (complains of) (headache severe). CT Head Scan recommended. She was transferred to Seton Medical Center. She refused ambulance transfer and her daughter ... will drive her directly to Seton Medical Center. Instructions were given. She was accepted at Seton Medical Center ER by (their MD) " . The final diagnosis was fall: head injury/scalp hematoma, facial abrasions. The transfer patient consent form showed the patient was transferred by privately owned vehicle. The patient disposition status was stable and was logged as a transfer. The transfer was documented to occur at 11:55 AM. Record review showed only a consent form was signed for transfer but there was no AMA form that was signed for an ambulance refusal.

9. Patient-26 was admitted to the ED on 5/13/15 at 7:00 AM with a chief complaint of intermittent 10/10 abdominal pain and nausea that started at 8:00 PM the night before. The patient was triaged at 7:06 AM with an ESI Level 3. The physical exam done by the physician as charted at 7:31 AM and showed the following: " Patient appears in pain ..., abdomen mildly distended; (moderate palpation tender) diffusely, max diffuse lower abdomen, without rebound, (bowel sounds) hypoactive ... at 7:35 AM Pt. will require (transfer) to higher level of care for further eval, including imaging studies unavailable at this facility. Discussed at 7:35 AM with (ER MD at Facility-B) who agrees to accept pt. in transfer via BLS " . The patient was treated with pain relief and anti-nausea medications. The disposition status was stable and was logged as a transfer. Record review revealed there were no transfer consent forms in the medical record nor was there documentation by the physician that risks and benefits of transfer were discussed with the patient. The ED nurse charted the patient left the department at 9:23 AM.

10. Patient-27 was admitted to the ED on 2/10/15 with a chief complaint of sharp back pain. An initial greet time was not documented but the first set of vital signs were taken at 11:49 AM. The patient was triaged at 12:02 PM with an ESI Level 3. The physical exam by the physician was charted at 12:48 PM and showed the following: " Patient appears in pain ..., (minimal) suprapubic (palpation tender) ?L>R (questionable left side greater than right) ..., (Symptoms) suggest musculoskeletal etiology ..., must r/o renal colic. Discussed at (12:35 PM) with (ED MD at Facility-A) who agrees to accept pt. in transfer via private vehicle - pt. refused ambulance transport " . The transfer form showed the patient was sent in a privately owned vehicle and this patient had a signed AMA form in the medical record for refusing an ambulance. The disposition status was stable and was logged as a transfer which was documented to occur at 1:00 PM.

11. Patient-29 was admitted to the ED on 12/03/14 at 9:55 AM with an initial complaint of worsening and constant left lower abdominal pain over the past five days. The patient was triaged at 10:16 AM and had an ESI Level 3. The patient was seen by his primary physician two days prior and was diagnosed with diverticulitis and was given an antibiotic which was not helping. The physical exam by the physician was charted at 10:39 AM and showed the following: " Patient appears in moderate pain distress ... abdominal exam included findings of abdomen tender, to the left lower quadrant, severe intensity, peritoneal signs present, rebound present ..., (MD at) Seton Daly City ... accepts pt. for transfer. Pt. however declined recommended ambulance transfer and so will be (discharged) and recommended to go immediately by private vehicle to Seton. Pt. asserts that he will follow recommendation " . The transfer time and vital signs were not documented on the transfer form. The form showed the patient was transferred by privately owned vehicle but the acknowledgment was completed differently than the other patients already discussed in this report: the section of the consent was checked at " Patient Refusal to Transfer " only and in this section the following was handwritten: " Pt. refused transfer- discharged. To go immediately to Seton Medical Center Daly City " .

During an interview on 5/18/15 at 9:00 AM, MD-2 stated that after a meeting with the hospital, the ED physicians at Coastside were told they should discharge patients who refuse transfers by ambulance and go in their privately owned vehicles. The disposition status of Patient-29 was stable and the log showed the patient as AMA. There was no AMA form in the medical record.

12. Patient-30 was admitted to the ED on 01/12/15 at 8:14 PM with a chief complaint of constant left lower abdominal pain for three days. The patient was triaged at 8:39 PM and had an ESI Level 3. The physical exam by the physician was charted at 9:18 PM and showed the following: " Patient appears uncomfortable ..., patient appears in pain ..., abdomen tender, severe intensity, left lower quadrant ..., I told him I thought there was at least a 50% chance of diverticulitis and if not diagnosed and treated there was risk of rupture leading to possible abscess and/or peritonitis with those requiring possible surgery and in the case of the latter risk of death. Advised he needed a CT scan of the abdomen not available here. Advised time was of the essence. He asked if it could wait until tomorrow for the scan and I told him no. He wants to go by car and is willing to go but not if he has to go in an ambulance. Risk of going by car discussed and I advised him I could not recommend that mode of transportation. One concern is that he may eat or drink prior to arrival and I advised him this was definitely not permissible until examining MD at Seton in Daly City allow it. He agreed to go directly there without eating or drinking. He signed an AMA form which I wrote with the specifics of what I was advising and what he was refusing and went over it in detail with him before he signed. He expressed understanding of each point. I called (the ED MD) at Seton who accepts pt. for transfer and know he will come by car. Transfer form was filled and sent with pt ... " . The transfer form showed the patient was transferred by private car and an AMA form was signed by the patient. The disposition status was stable and was logged as a transfer. The final diagnosis was left lower quadrant pain, r/o diverticulitis. However, the second page of the transfer form was not in the medical record. The second page would show the updated vital signs, patient status, and time when the transfer occurred.

13. Patient-31 was a 17 year old who was admitted to the ED on 9/01/14 at 11:39 AM with a chief complaint of " took drugs " . The patient was triaged at 12:11 PM and an ESI Level was not assigned. The ED log was also incomplete of an ESI Level. The physician ' s history and physical exam was charted starting at 12:22 PM and showed the following: " Parents brought in 17 year old who is acting very paranoid. States he does not want to be enclosed. Rambles about coming to conclusion of " seeing the light " and the mission of goodness in his life. That he has been surrounded by people who want him to do bad but he is resisting. He denies drug or alcohol use. States he did not sleep last night ..., Sudden onset of symptoms, within last 36 hours ..., blood pressure is outside normal limits (203/102 sitting) ..., I had sheriff ...evaluate patient and they declined to place him on hold. Parents were willing to go voluntarily with him to (Facility-B) where he can be properly evaluated to r/o ingestion vs. paranoid state. I spoke with (MD at Facility-B) accepting him in transfer " . The final diagnosis was paranoia. The disposition status was stable and was logged as a transfer. The transfer form showed the patient was transferred via private car. And the updated blood pressure on the transfer form was still 203/102 even though the doctor documented the patient was stable. The transfer was documented to occur at 1:00 PM. Record review revealed the consent form was not signed by the parent or patient and the record did not reveal whether the provider discussed ambulance transfer.

14. Patient-32 was admitted to the ED on 11/06/14 at 11:29 AM with a chief complaint of rib injury after hitting a deer on the road after driving between 45-50 mph 6:00 PM last night. The patient was triaged at 11:39 AM with an ESI Level 3. The history and physical exam done by the physician was charted starting at 12:00 PM and showed the following: " ...impact caused car to skid and roll over, landing on roof 20 feet away - estimates 2 min. (loss of consciousness) before finding himself upside down in vehicle. (Complains of) pain left lateral ribs and right knee. Drank wine for pain control last night, then felt nausea so induced vomiting; no (stomach) symptoms since ..., minimal (palpation) tenderness right medial knee ..., superficial abrasions left lower ... neck and left ... forearm ..., historian reports chest pain ..., left (lateral) chest wall pain ..., Discussed with Trauma Attending at (Facility-D) who agrees that given mechanism of injury with (loss of consciousness), CT scan head indicated. As this is unavailable at this facility, pt. to be transferred ..., Plan discussed with pt. who adamantly refuses ambulance transport, insisting that his partner drive him to (Facility-D); pt. advised of risks, including death, of so doing, but he continues to insist. Therefore, he will leave AMA, after completion of ordered tests available here " . Record review revealed only an AMA form was signed by the patient and not consent for transfer. The disposition status was stable and was logged as a transfer. The record showed the patient left the department at 1:52 PM.